Newly Designed Upper Lateral Cartilage Flap for Preventing Depression of the Keystone Area in Large-Nose Septorhinoplasty

Abstract

IMPORTANCE Because large dorsal reduction may weaken the keystone area, later notching of this area should be prevented while reducing large humps during septorhinoplasty. OBJECTIVE To determine whether a triangular-shaped flap of upper lateral cartilages (ULCs) that we designed can prevent secondary deformity of the nasal dorsum in the keystone area following large hump reduction. DESIGN, SETTING, AND PARTICIPANTS In this retrospective study, medical records as well as preoperative and postoperative photographs of septorhinoplasty cases in which triangular flaps had been used between April 1, 2012, and March 3, 2013, were reviewed. Data analysis was conducted from March 3 to May 10, 2014. Demographic data, amount of hump reduction, and any irregularity of the dorsum in the keystone area mentioned in the medical record or identified in postoperative profile view photographs were assessed. The study was conducted in a research center, and the operations were performed in a private setting. Patients had been scheduled for septorhinoplasty with flap reconstruction if more than 3 mm of dorsal hump reduction was planned and their skin was not thin. Of 41 identified patients, 3 could not be monitored for 1 year; 38 patients were included in the analysis. EXPOSURES Open septorhinoplasty had been performed, and more than 3 mm of dorsum had been removed in all patients whose data were analyzed. During stepwise resection of the nasal dorsum, a triangular-shaped remnant of the most cephalomedial part of the ULC was maintained intact on each side over the keystone area. MAIN OUTCOMES AND MEASURES Irregularity of the nasal dorsum over the keystone area in postoperative profile view photographs. RESULTS More than 3 mm of hump reduction had been made in all 38 patients. No irregularities were observed in the postoperative photographs or had been found on digital examination of the keystone area after at least 12 months of follow-up. CONCLUSION AND RELEVANCE Maintaining a remnant of the ULC over the keystone area in the form of a triangular-shaped flap on each side is a simple, reliable, and durable way to prevent notching of the keystone area during lowering of the nasal dorsum in large noses with sufficient skin thickness. LEVEL OF EVIDENCE 4.

Modified perichondrial-periosteal flaps to camouflage nasal dorsum in rhinoplasty

“…Complications such as visibility of edge, displacement, infection, and extrusion were documented with onlay graft [10]. Others used ULC flaps to avoid these irregularities to prevent keystone notching of the nasal dorsum after surgery [11,12].…”

Once Upon a Rhinoplasty: The History of the “Queen” of Facial Plastic Surgery

“…102,103 With the earlier (over) reductions, long-term sequelae such as rhinion depressions and middle third collapse were noted, and new techniques were introduced to prevent and treat these deformities. 21,[104][105][106][107][108] Most importantly, the variation in dorsal skin thickness was recognized to mandate that the rhinion be reduced less to avoid a sloop and also that bony overresection often leads to an unnatural sloop or pollybeak deformity. 102 Spacer grafts to fill in the rhinion followed by spreader grafts to prevent middle third collapse, widen the middle third, or straighten and strengthen the middle third were popularized in the 1980s.…”

“…109 In an effort to minimize cartilage grafting requirements, the preservation of medial and cephalad upper lateral cartilage was recommended. 107,110 Upper lateral cartilage turn-in flaps were similarly created to preserve cartilage and achieve ideal middle third aesthetics while maintaining structural strength. 111 The importance of suture stabilizing the upper lateral cartilage-septal complex became recognized and virtually universally applied.…”

Classification of Nasal Deviation

“…Medial, medial oblique, lateral, intermedial and transverse osteotomies are required as per the severity of the deviation. Camouflage nasal dorsum and/or the short concaved side-wall could be essentially required [14][15][16].…”